In October 2015, the former Prime Minister of Nunavut (one of the northernmost Territories in Canada) Peter Taptuna announced a suicide crisis. Aboriginal people in Canada comprise First Nations, Metis, and Inuit. According to Statistics Canada, Inuits comprise 27,070 of the 27,360 aboriginal people living in Nunavut. Furthermore, 57% of the Inuits are under the age of 25 in comparison to 19% in the non-Aboriginal population. The Centre for Suicide Prevention in Canada reports that the suicide rate in male youth ages 15-24 is more than 5 times the rate (126 per 100,000) when compared to non aboriginal male youth (24 per 100,000). In females the suicide rate is seven times more (35 per 100,000) compared to non aboriginal females (5 per 100,000). Of numerous journal articles, one by Michael J. Kral in 2016 points to the widespread mental health issues in aboriginal communities including but not limited to depression, alcohol, and drug abuse. The article also points to colonization as a root cause of historical trauma, deculturalization, and isolation in the aboriginal population in Canada which further predisposes the group to suicide.

Local non profit agencies in Nunavut like Embrace Life have created culturally specific helplines for youth contemplating suicide. Collaborations like Connected North between the renowned Hospital for Sick Children in Toronto, Royal Bank Canada, and Cisco Canada (a computer agency) are working to launch tele-psychiatry programs in order for adolescents to access health care services related to mental health and addictions. The government of Nunavut has made addressing the suicide crisis a priority. Having created a website, specific strategies have been elucidated by the government of Nunavut to help curb suicide rates. One creative strategy includes YouTube videos for individuals to break their silence on suicidality.

However, the government of Nunavut and local public and private agencies cannot eliminate suicide on their own. It is necessary that the Federal Government of Canada provides funding to the territory of Nunavut to create a culturally specific crisis centre for Inuit youth with information in their native language and access to elders to provide social, spiritual, and cultural support. The crisis centre would be a hub for the Nunavut community to train staff, work closely with researchers, and promote strength based programming to ultimately reduce rates of youth suicide and improve the mental health of the Inuit and aboriginal youth population in Nunavut.

SOURCE: PARTNERS IN HEALTH

The Navajo Nation spans across Arizona, New Mexico and Utah, and has ~300,000 enrolled tribal members. The Indian Health Service estimates that 1/3 of Navajo tribal members are Type 2 diabetic or are pre-diabetic, and over half are overweight or obese. In an effort to combat these rates of obesity and diabetes, the Navajo Nation government enacted the Healthy Diné Nation Act in 2014. This policy mandates a 2% tax on “unhealthy” (processed/junk foods) with the ultimate goal of disincentivizing the purchase of these foods. The money collected is redistributed to the local tribal government chapter houses to implement community health initiatives.

SOURCE: PARTNERS IN HEALTH

While the idea of taxing junk food and putting those funds towards community health initiatives seems like a step in the right direction, the potential unintended consequences should be considered. 1/3 of Navajo people do not have electricity or running water, and the vast majority qualify as “food insecure” and have to drive an average of 1 hour (60+ miles) to get to a grocery store. 80 percent of the Navajo grocery stores’ inventory qualified as junk food. It could be argued that a junk food tax on a population that is both food insecure and predominately living at or below the poverty line could perpetuate the cycle of poverty. The larger, structural issue at hand is the food system on Navajo Nation. There are only 13 grocery stores across 27,000 square miles of land, limited access to electricity (to store fresh fruits and vegetables) and a harsh high desert climate (with short growing seasons). These limit the ability of tribal members to access health foods and practice food sovereignty, thus perpetuating the dependence on processed foods. Enacting policies upon groceries stores who wish to sell on tribal land that limit the amount of junk food they sell and set standard pricing for fresh fruits and vegetables would be a better option for addressing high obesity and diabetes rates. This puts the responsibility back onto the food industry (which establishes the food environment) rather on the individual (who is a product of the environment), and enables the Navajo Nation government to enforce autonomy within their food system.

CNMI college students educate children and their parents on sugar content in commonly purchased beverages at a community event in 2016. Credit: Kaitlyn Neises-Mocanu

Factors which determine our health include the environments in which we live, work and play: these factors exist outside the clinic walls and beyond the range of our public health services. Improving the health of our population in the Commonwealth of the Northern Mariana Islands (CNMI) requires an environment which supports healthy choices.

Inflatable Coca-Cola advertisement at the same community event photographed above. Credit: Kaitlyn Neises-Mocanu

We are inundated by a “culture” of sugary drinks created by the beverage industry, promoting the over-consumption of sugary drinks. According to the 2016 CNMI Non-Communicable Disease and Risk Factor survey, nearly three out of four (74.1%) CNMI adults drink at least one sugar-sweetened beverage every day.

If we expect our neighbors to make healthy lifestyle choices, the healthy choice needs to be the easy choice. When unhealthy beverages are cheap, deceptively marketed, and dominate beverage coolers at every mom and pop store, we make drink choices at the cost of our own health. A tax on sugar-sweetened beverages brings down consumption levels, incentivizes distributors and retailers to stock healthier beverage options, and has the potential to change beliefs, attitudes and norms about sugary drink consumption.

Source: 2016 CNMI NCD Risk Factor and Behavior Survey

As an added benefit, a tax on sugary drinks raises much-needed revenue for diabetes prevention and management programs, opens up a funding resource for local groups who want to improve health in their communities, and supports the CNMI’s only hospital.

Our government is responsible for protecting the health of the public, and when products which detriment our health, like sugary drinks, are heavily marketed and sold cheaply in our community, action must be taken. Encourage CNMI Legislators to send the message that the health of our people is a priority, and urge them to take action to increase the tax on sugary drink distribution.

There are countless examples of health care disparities among Canada’s First Nation populations – tuberculosis rates up to 38 times higher, diabetes rates 4 times higher and poor housing conditions 3 times higher than non-Aboriginal communities. One of the most significant deficiencies is provision of mental health services, particularly to Canada’s Indigenous youth. Alarmingly, the suicide rates of First Nations youth is 5-6 times higher than the non-aboriginal population.

Delivery of health services to Canada’s Indigenous populations is complex, as funding is divided between provincial/territorial and federal governments. The lack of clarity in legislation around this division has led to significant delays in patient care. In 2005, Jordan River Anderson, a 5-year-old Cree boy with a neuromuscular disorder died in hospital. It had been determined several years before that he could have been cared for at home, however the dispute over funding for this care extended longer than Jordan survived. This lead to the development of Jordan’s Principle with the intent to prevent First Nations children from being denied services or experiencing delays receiving them.

Despite Jordan’s Principle being passed in 2007, the Canadian Human Rights Tribunal recently ruled that the federal government is discriminating against First Nation children by failing to provide equivalent health services compared to non-Aboriginal communities. When a suicide pact was uncovered among youth in Wapekeka, an urgent request for support was issued to Health Canada – it was not provided until after the deaths of two local teenagers. The Canadian Paediatric Society has found significant discrepancies in how Jordan’s principle is implemented in each province/territory.

LEGAL + AVAILABLE ≠ ACCESSIBLE

Over the past decade Ontario has seen a steady rise in the number of opioid related deaths and narcotic misuse across all socioeconomic groups in the province. Of particular concern is that despite ongoing provincial initiatives little has been accomplished to prevent the rampant abuse and misuse of narcotic pain medications. The opioid epidemic is a public health crisis of epic proportions. Recently it has been estimated that 1 in 8 deaths in Ontario is related to opioid abuse.

These recent policy initiatives from the provincial government to combat the provinces growing opioid crisis are welcome news. The problem represents a complex health issue with potentially devastating consequences for individuals, families and the communities they live in. Unfortunately the crisis continues to grow and these efforts do not go far enough to help prevent the senseless deaths that are occurring every day on the streets of our cities from accidental overdoses.

Historically the use of the lifesaving antidote for an opioid overdose, Naloxone was only available to a select group of healthcare providers like physicians and paramedics. Most recently this past year the provincial government reduced the restrictions on this lifesaving medication making it available in local pharmacies to consumers without requiring a prescription.

This is a welcome policy change that will save lives….unless you live in Grassy Narrows, Attawapiskat, Pikangikum, White Dog, or any of the other remote Northern Ontario First Nation reserves where there are no pharmacies or publicly available free Naloxone kits. You may not find these communities listed on the provincial government website ‘Where to get a free naloxone kit’ but deaths from overdoses are happening here at alarming rates.

While there is strong support for this new policy change, simply removing the legal barriers and improving the availability of this life saving intervention may not equal improved accessibility for some residents of Ontario.

LEGAL + AVAILABLE ≠ ACCESSIBLE

Major health disparities exist amongst remote First Nations communities living in Northern Ontario. These populations are socially marginalized and medically underserviced. Access to healthcare for these populations is limited as is the quality, equity and timeliness of the healthcare they do receive. This results in disproportionately high burdens of disease and poor health outcomes. First Nations youth have higher rates of suicide and an increase prevalence of risk taking behaviours which can all lead to higher rates of alcohol and drug abuse and ultimately death from overdose.

The government’s expansion of initiatives and services which take aim at combating the opioid epidemic in Canada need to target all Canadians and not just those living in urban centers. If the government is serious about broadening access to initiatives like free Naloxone it needs to couple that with initiatives to ensure these initiatives reach the most vulnerable and disadvantaged members of society like the remote First Nation reserves of Northern Ontario. There needs to be a global expansion of healthcare funding for Aboriginal populations that aims to reduce the health disparities that currently exist in these populations. Otherwise available does not equal accessible.

In 1975, the Indian Self Determination and Education Assistance Act (PL-93-638) was passed to allow for tribes to contract with federal agencies to govern their own services. Tribes, considered “dependent domestic nations”, have varied in how much they have taken advantage of self-determination opportunities in health care. For example, 99% of the Indian Health Service (IHS) funding in the Alaska Area is under tribal control, while very little of the Great Plains Area has been transferred to tribal control. Under treaty rights, the federal government is responsible for the “proper care and treatment” of members of recognized tribes in perpetuity. There exists some sentiment that self-determination is a way of letting the federal government out of its treaty responsibilities to Native people. Others, like Donald Warne, MD, MPH, see so-called “638” tribally-managed health care as offering increased opportunities for third party revenue and grant funding, and increased local control versus IHS facilities, resulting in more services and better access.

AI/AN health care funds are not considered an entitlement like Medicare, Medicaid, or VA benefits, meaning that Congress must appropriate funding annually. In 2014, this was $3099 per user, which is less than that spent on federal prisoners. In comparison to the general US population, AI/AN people suffer higher age-adjusted death rates (from diabetes, chronic liver disease and cirrhosis, accidents, tuberculosis, pneumonia and influenza, suicide, homicide, and heart disease), as well as infant mortality twice the general population. IHS is a severely underfunded and understaffed agency, which, at least in the Great Plains Area, is providing care which Senator John Barrasso (R-Wy) recently called “malpractice”.

I am calling upon the IHS to provide technical assistance, capacity development, and transfer planning for tribal control. I am also calling upon Congress to fund these efforts for the improvement of AI/AN health.

If asked which parasitic disease were responsible for the greatest burden of morbidity, the majority of us would likely respond with HIV or perhaps malaria. In actuality, the biggest cause of Disability-Adjusted Life Years (DALYs) are due to what health expert Dr. Peter Hotez refers to as “the unholy trinity”: Roundworm, Whipworm, and Hookworm.Collectively, these worms are known as “Soil-Transmitted Helminths” or STHs. Current data show that up to 35% of people in the Amazon region are chronically infected by STHs (up to 75% in some villages!), many of them children. STH infection can be especially pernicious in the young, due the detrimental effects of parasitic burden – chiefly anemia – which result in reduced cognitive and physical function and compromised academic performance. Moreover, these infections trend highly with impoverished and underprivileged populations.

Fortunately, there exist clear and cost-effective interventions for STH infections. Mass Drug Administration (MDA) with anti-helminthic medications remains the gold standard, is cheap to implement, and has a proven track record of effectiveness in numerous countries. In order to complete a successful intervention in Ecuador, it will be necessary to engage stakeholders at all levels of involvement. Organizations like the Bill and Melinda Gates Foundation and the Sabin Institute can provide required funding and strategic planning, with branches devoted entirely to neglected tropical diseases. PAHO can also help with active implementation of deworming efforts, but interventions will require cooperation from indigenous nations (CONFENIAE) and Ecuador’s Ministry of Health. By strategically combining the resources and aims of these key stakeholders, a successful deworming campaign could finally end the vicious cycle of helminth infection that disproportionately affects the impoverished young and perpetuates their socioeconomic handicap.

The problem has been thoroughly researched and recognized by the government for years now… tens of thousands of head injuries or deaths of motorcycle drivers and passengers in Thailand, many of which were preventable by helmets.

Although helmet use has been mandated for motorcycle drivers and passengers since 1994 and 2007, respectively, rates of helmet use are still strikingly low in rural areas, hovering around one third for adults and only 1% for children in the Chiang Mai North Region, according to the Thai Accident Research Center which specializes in investigating auto accidents. A survey of approximately 4,000 motorcyclists in Thailand revealed that 15% were not even aware of the helmet law for motorcycle passengers. The relative risk for fatality by accident is as high as 4.5 times greater than for those who wear helmets in the Surat Thani South Region.

To combat low use of helmets, organizations have collaborated with the Thai Ministry of Interior to educate communities regarding the importance of helmet use, such as AIP Foundation which launched the Thailand Helmet Vaccine Initiative. However, with less than half of Thai motorcyclists wearing helmets, the need for a stronger collaboration between government, public organizations, private sector, and communities is urgent.

Many people and organizations can benefit from getting the public to adopt helmets when traveling by motorbike. Efforts in raising public awareness of the importance of helmet use need to be further strengthened, especially in hard-to-reach areas, in conjunction with tougher enforcement by the Royal Thai Police.

Indigenous Guatemalan women generally lack broad access to family planning services. Their awareness and usage of contraception is much lower than their Latina counterparts, resulting in many indigenous women having a high number of pregnancies over their lifetime, often more pregnancies than they wish to have. These women have worse health compared to other Guatemalans, and are often unable to adequately provide for all the children they bear. On a long-term basis, the large size of these indigenous families and their relatively poor health contributes to their position as the most impoverished and marginalized members of society.

The efforts of the Catholic Church and religious groups like Catholic Relief Services to reduce suffering among indigenous Guatemalans are commendable. Unfortunately, their hard-line stance against contraception and family planning directly contributes to poor health outcomes among those they aim to help.

Above all, the discourse must incorporate the indigenous women’s perspective. Aid groups, even religious ones, should work with the Guatemalan government to empower indigenous women, encouraging them to take control of their reproductive and sexual health, and helping them make informed, responsible decisions to improve their health and the health of their children.

Suicide is the second leading cause of death among American Indian youth. In some communities, the suicide rate is as high as ten times the rate of the general U.S. population, requiring immediate attention. Like many public health issues, suicide is complex and influenced by multiple factors, including parental conflict, academic problems, substance abuse, and socioeconomic status. Although limited research exists on protective factors for American Indians, studies have found that positive school experience, supportive tribal leaders, and commitment to cultural spirituality were protective against suicidal thoughts. [1]. While these factors provide a good starting point for program development, suicide prevention programs must be flexible to account for differences between tribes, such as social structure, gender roles and conceptualization of death. [1]

Despite these efforts, more is needed. We need additional funding for American Indian youth suicide prevention programs. Early research shows that suicide prevention programs can be effective. Now, we simply need the funding to implement these programs. It is a matter of life and death for our children, our communities, and our future.

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[1] Balis, T. and Postolache, T. (2008). Ethnic Differences in Adolescent Suicide in the United States. International Journal of Child Health and Human Development, 1(3), 281-296.